U.S. patent application number 12/165777 was filed with the patent office on 2010-01-07 for system and method for providing health management services to a population of members.
Invention is credited to Jeff Brizzolara, Mark Head, Michael Nadeau, David Smith.
Application Number | 20100004947 12/165777 |
Document ID | / |
Family ID | 41465075 |
Filed Date | 2010-01-07 |
United States Patent
Application |
20100004947 |
Kind Code |
A1 |
Nadeau; Michael ; et
al. |
January 7, 2010 |
System and Method for Providing Health Management Services to a
Population of Members
Abstract
A preferred embodiment comprises providing heath management
services by collecting member assessment data, collecting member
biometric data, and generating risk factors for one or more members
based upon the member assessment data and the member biometric
data. The risk factors are analyzed using a set of rules to
stratify the member population based upon risk and wellness
coaching and outreach services are provided the population based
upon risk levels.
Inventors: |
Nadeau; Michael; (Dallas,
TX) ; Head; Mark; (Dallas, TX) ; Smith;
David; (Coppell, TX) ; Brizzolara; Jeff;
(Dallas, TX) |
Correspondence
Address: |
FOGARTY, L.L.C.
P.O. Box 703695
Dallas
TX
75370-3695
US
|
Family ID: |
41465075 |
Appl. No.: |
12/165777 |
Filed: |
July 1, 2008 |
Current U.S.
Class: |
705/3 |
Current CPC
Class: |
G16H 10/20 20180101;
G16H 50/20 20180101; G16H 50/30 20180101; G06Q 40/08 20130101; G16H
50/70 20180101 |
Class at
Publication: |
705/3 |
International
Class: |
G06F 19/00 20060101
G06F019/00 |
Claims
1. A method for providing health management services, comprising:
collecting member health assessment data; collecting member
biometric data; identifying risk factors for each members based
upon the member assessment data and the member biometric data;
calculating a health score for each member based upon the member
health assessment data and the member biometric data; stratifying a
member population by applying a set of rules to the health scores
and risk factors; and selecting one or more outreach programs for
the population based upon member risk levels.
2. The method of claim 1, further comprising: selecting a group of
members for health management coaching based upon the members' risk
levels.
3. The method of claim 2, wherein the coaching comprises
encouraging one or more members to participate in one or more of
the following: competitions; challenges; exercise programs;
nutrition programs; and educational programs.
4. The method of claim 1, further comprising: monitoring members'
participation in incentive programs.
5. The method of claim 1, wherein member health assessment data
comprises members' self-evaluation of the members' own health,
nutrition, physical activity, stress, tobacco use, alcohol use and
sleep habits.
6. The method of claim 5, wherein health assessment data is
collected using one or more questions, wherein potential answers to
each of the one or more questions are assigned a point value, and
wherein the point values for each of a member's answers are
combined while calculating the member's health score.
7. The method of claim 5, wherein health assessment data is
collected using one or more questions, wherein potential answers to
each of the one or more questions are assigned a risk level, and
wherein the risk level for each of a member's answers are evaluated
when identifying the member's risk factors.
8. The method of claim 1, wherein the member biometric data
comprises objective measurement of individual members' blood
pressure, cholesterol, triglycerides, glucose, and body mass
index.
9. The method of claim 8, wherein different measurement ranges of
biometric data are assigned a point value, and wherein the point
values for each of a member's biometric data measurements are
combined while calculating the member's health score.
10. The method of claim 8, wherein different measurement ranges of
biometric data are assigned a risk level, and wherein the risk
levels for each of a member's biometric data measurements are
evaluated when identifying the member's risk factors.
11. A method of providing health management services, comprising:
selecting one or more individuals to be contacted regarding health
management issues, the one or more individuals selected based upon
at least one targeted risk factor; and contacting the one or more
individuals via one or more communication formats selected from a
plurality of communication formats.
12. The method of claim 11, wherein the selecting the one or more
individuals further comprises: applying an outreach template to a
group of health plan members, wherein the template identifies
specific risk factors of interest and particular risk levels for
the specific risk factors.
13. The method of claim 12, further comprising: applying the
outreach template to the group of health plan members at periodic
intervals.
14. The method of claim 12, wherein the group of health plan
members are associated with a common employer.
15. The method of claim 12, wherein the group of health plan
members selected from a database of health plan members; and
wherein the database of health plan members are associated with a
plurality of employers and insurance providers.
16. The method of claim 12, further comprising: stratifying the one
or more members based upon risk levels of a risk factor in the
template; and prioritizing a contact order for the one or more
members to be contacted based upon the members' risk level.
17. The method of claim 11, wherein the plurality of communication
formats comprise: secure messaging, electronic mail, telephone
communications, and postal mail.
18. A method for providing health management services, comprising:
providing a database of member data, the member data comprising
risk factors, risk levels and health scores for each of a plurality
of members; applying an outreach template to the database to
identify selected members, the template identifying particular risk
factors and risk levels; and providing contact information for the
selected members to one or more outreach professionals.
19. The method of claim 18, further comprising: providing outreach
information to the one or more outreach professionals, the outreach
information associated with one or more of the particular risk
factors; providing the outreach information to the selected members
by the outreach professional.
20. The method of claim 19, wherein the outreach information is
scripted text.
21. The method of claim 20, wherein the outreach information is
notification of a member assessment activity.
22. A method for providing health care cost information to a health
care plan provider, comprising: analyzing health care claims data
based upon member risk factors to develop a cost per risk factor
per year for one or more risk factors.
23. The method of claim 22, further comprising: stratifying the
cost per risk factor per year based upon risk levels.
24. The method of claim 22, further comprising: stratifying the
cost per risk factor per year based upon cost.
25. The method of claim 22, wherein the cost per risk factor per
year is an average for a group of employees.
26. The method of claim 22, wherein the cost per risk factor per
year is calculated for each employee within a group of
employees.
27. The method of claim 22, further comprising: providing a
comparison of a selected employer's cost per risk factor per year
to a competitor's cost per risk factor per year.
Description
TECHNICAL FIELD
[0001] The present invention relates generally to systems and
methods for providing health management services to and promoting
wellness within a population of members and, more particularly, to
systems and methods for identifying and acting on members based
upon the members' risk levels.
BACKGROUND
[0002] Traditional healthcare is focused upon disease management
after patients have been diagnosed with an illness with minimal
attention on trying to prevent disease in the first place. Patients
seek medical services for diseases and illnesses that they are
already experiencing. An insurance company or a medical provider
may assign a case worker to a member or patient to assist in
managing an existing disease. The case worker may assist the member
in complying with a prescribed treatment plan. Insurance claims
filed by members may be used by an insurance company to identify
and select members who would benefit from assistance to manage a
disease or illness. This approach may help to reduce medical costs
associated with an existing disease or illness, but it does not
provide disease prevention for members who are at risk for
developing a disease or illness.
SUMMARY OF THE INVENTION
[0003] These and other problems are generally solved or
circumvented by embodiments of the present inventive system and
method in which members' health management and wellness is promoted
and encouraged by identifying members' risk levels and coaching
members to participate in activities that reduce risk factors for
disease and illnesses. The present inventive system and methods
result in a population of members that is more healthy and that has
a reduced need for disease management services and medical
treatment. In turn this lowers the healthcare costs for the
members.
[0004] In accordance with a preferred embodiment of the present
invention, a method for providing health management services
comprises collecting member assessment data, collecting member
biometric data, and generating risk factors and a health score for
one or more members based upon the member assessment data and the
member biometric data. The risk factors are analyzed using a set of
rules to identify high, moderate, and low-risk populations and
wellness coaching is provided to each population.
[0005] In another embodiment, a method of providing health
management services comprises selecting one or more individuals to
be contacted regarding health management issues, the one or more
individuals selected based upon at least one targeted risk factor,
and contacting the one or more individuals via one or more
communication formats selected from a plurality of communication
formats. The selecting the one or more individuals may further
comprise applying an outreach template to a group of health plan
members, wherein the template identifies specific risk factors of
interest and particular risk levels for the specific risk factors.
The outreach template may be applied to the group of health plan
members at periodic intervals. The group of health plan members may
be associated with a common employer. The group of health plan
members may be selected from a database of health plan members, and
the database of health plan members may be associated with a
plurality of employers and insurance providers. The one or more
members may be stratified based upon risk levels of a risk factor
in the template, and prioritized in a contact order based upon the
members' risk level. The plurality of communication formats
comprise: secure messaging, electronic mail, telephone
communications, and postal mail. In other embodiments, outreach
professionals and/or coaches may meet with members or communicate
information to members in person, such as during on-site meetings
at a member's place of employment or other location. Such on-site
meetings may include workshops, health classes, health assessments
or screenings, or group or one-on-one coaching.
[0006] In a further embodiment, a method for providing health
management services comprises providing a database of member data,
the member data comprising risk factors, risk levels and health
scores for each of a plurality of members; applying an outreach
template to the database to identify selected members, the template
identifying particular risk factors and risk levels; and providing
contact information for the selected members to one or more
outreach professionals. The outreach information may be provided to
the one or more outreach professionals, the outreach information
associated with one or more of the particular risk factors. The
outreach professionals may provide the outreach information to the
selected members. The outreach information may be scripted text or
a notification of a member assessment activity, for example.
[0007] In another embodiment, a method for providing health care
cost information to a health care plan provider comprises analyzing
health care claims data based upon member risk factors to develop a
cost per risk factor per year for one or more risk factors. The
cost per risk factor per year may be stratified based upon risk
levels or cost. The cost per risk factor per year may be for an
average for a group of employees or may be calculated for each
employee within a group of employees. A comparison of a selected
employer's cost per risk factor per year to a competitor's cost per
risk factor per year may be provided.
BRIEF DESCRIPTION OF THE DRAWINGS
[0008] For a more complete understanding of the present invention,
and the advantages thereof, reference is now made to the following
descriptions taken in conjunction with the accompanying drawings,
in which:
[0009] FIG. 1 is an overview of one embodiment of a heath
management and wellness service; and
[0010] FIG. 2 is a flowchart illustrating a method for implementing
one embodiment of the present invention.
DETAILED DESCRIPTION OF ILLUSTRATIVE EMBODIMENTS
[0011] The present invention provides many applicable inventive
concepts that can be embodied in a wide variety of specific
contexts. The specific embodiments discussed herein are merely
illustrative of specific ways to make and use the invention, and do
not limit the scope of the invention.
[0012] FIG. 1 illustrates one embodiment of health management
system 100. Member assessment database 101 is collected for one or
more members of a group, such as a group of employees or a group of
health insurance plan members. The member assessment data may
include, for example, information about the members' living,
eating, working, exercising, and other activities and habits.
Member assessment data 101 may be collected from members using any
number of methods. For example, member assessment data may be
collected using a survey or questionnaire filled out by the
members. In one embodiment, an electronic survey or questionnaire
may be accessed by members on-line via the Internet or any other
public or private data network using, for example, terminal 102.
Alternatively, in other embodiments, the members may fill out a
paper or hardcopy survey to provide member assessment data.
Questions in a member assessment survey may include, for example,
questions directed to the members' age, sex, ethnicity, overall
health, medications currently used, recent doctor visits, past
and/or current illnesses, home and work environment, physical
activity, use of tobacco products, and/or sleeping and eating
habits. Generally, the member assessment data comprises subjective
answers that are self-reported by the member.
[0013] Biometric data 103 may also be collected from the group
members. Member biometric data 103 may include, for example,
height, weight, blood pressure, heart rate, cholesterol levels,
body mass index, and the like. The member biometric data 103
generally consists of objective data that may be collected, for
example, by a health or medical professional at a clinic, doctor's
office, place of employment or other location.
[0014] Member claim data 104 may also be collected for use in some
embodiments of the present invention. Claim data may be collected
directly from the members, from insurance companies, claim
processing entities, and the like. Member claim data 104 may
include information associated with health or other insurance
claims filed by members. For example, member claims data 104 may
include information regarding requests for coverage or
reimbursement for medical services such as hospital, clinic, and/or
doctor office visits and treatment, prescription medication costs,
medical treatment, physical therapy, rehabilitation treatment, and
the like.
[0015] Health score engine 105 receives or pulls information from
member assessment database 101, member biometric database 103
and/or member claims database 104. Health score engine 105
generates a health score for one or more members. Health score
engine 105 uses a health score algorithm that applies a weighted
ranking to the assessment, biometric and claim information
collected for the member. In one embodiment, a point value is
assigned to each question or category in a member assessment survey
and, after the member completes the survey, the health score
algorithm calculates the member's score. For example, a question
regarding whether the member is a smoker may be assigned a high
point value if the answer is no and a low point value if the answer
is yes. In other embodiments, a weighted point value may be
assigned to the members' biometric data. For example, a point value
may be assigned in direct or inverse proportion to the member's
body mass index, cholesterol, blood pressure measurements, and/or
other factors. Weighted point values may also be assigned to
factors collected from member claims data, such as the cost and/or
frequency of treatment, severity of injury or illness, and the
like.
[0016] It will be understood that point values may be assigned to
health score factors using any numerical range depending, for
example, upon the granularity desired in the final health score.
Moreover, it will be understood that relative size of the point
values may represent either "good" or "bad" answers or measurements
for the respective factors. For example, in a system using binary
point values, a value of "0" may be assigned to answers or factors
that are absent or lower than a desired threshold, while a value of
"1" may be assigned if an answer or factor is present or higher
than the desired threshold. On the other hand, in a system having
more granularity, a value up to "100" may be assigned to answers or
factors that are absent or lower than a desired threshold, while a
value as low as "0" may be assigned if an answer or factor is
present or higher than the desired threshold. Moreover, systems and
methods embodying the present invention may use any number as the
maximum or minimum, and any numerical range may separate the
maximum and minimum values.
[0017] Health score engine 105 may add, average, or otherwise
combine the point values assigned to the assessment, biometric
measurements, and claims data to generate an overall member health
score. The resulting member health score may be saved to health
score database 106. The member, a health or medical professional,
such as a doctor, an outreach professional, or a wellness coach may
retrieve and view the member's health score using, for example,
terminal 102. Member health score database 106 may store a
plurality of health scores for a plurality of members. A member,
wellness coach or outreach professional, for example, may view
current and/or historical health scores for members. Additionally,
the health scores for a group of members, such as an employee
group, an insured group, or other collection of members, may be
aggregated and viewed by an administrator, wellness coach, outreach
professional or insurance agent. In one embodiment, outreach
professionals may include registered dieticians, registered nurses,
clinical professionals, and similar healthcare professionals.
[0018] Risk factor engine 107 may use data from member assessment
database 101, member biometric database 103, and/or member claim
database 104 to identify one or more risk factors for a member.
Risk factor engine 107 may reference a pre-defined group of risk
factors that are associated directly or indirectly with various
ones of the factors in the member assessment database 101 and/or
member biometric database 103. As used herein, the term risk factor
is defined as some variable, parameter or thing that increases a
person's chances of developing a disease. Risk factors may include,
for example, activities or subjective choices of a member, such as
use of tobacco products, eating habits; and/or objective
parameters, such as a member's age, family history of certain
diseases or types of cancer, obesity, and exposure to radiation or
other cancer-causing agents. Risk factors may be correlated to
certain diseases and illnesses, but are not necessarily the cause
of the disease or illness.
[0019] Each of the questions or categories in a member assessment
survey and each factor measured for the member's biometric data may
be assigned both a health score point value and a risk factor
value. Risk factor engine 107 analyzes the risk factors identified
in the members assessment data and biometric data and generates a
risk factor list for each member. For example, if a member has a
high LDL cholesterol value (i.e. a high level of "bad"
cholesterol), then the member's health score may be adversely
affected and the member may be identified as having risk factors
for clogged arteries and heart disease. Risk factors for members
may be stored in risk factor database 108.
[0020] Risk factor engine 107 may use a unified set of core life
style and biometric risk factors. Questions on a member assessment
may be used to evaluate the life style risk factors and to assign a
low, moderate or high risk to those factors. In one embodiment,
questions directed to the types and amounts of food that a member
eats, the frequency of the member's physical activity, and tobacco
use may provide data to evaluate the member's life style risk
factors. For example, if the member indicates tobacco use, then
that user may be identified as being at high risk for certain types
of cancer. Similarly, a medical screening, such as the member's
blood pressure, cholesterol, or BMI measurements, may be used to
identify biometric risk factors.
[0021] In some embodiments, only member assessment data and
biometric data are used by health score engine 105 and risk factor
engine 107. In other embodiments, health score engine 105 also uses
member claim data. The connection between member claims database
104 and health score engine 105 and risk factor engine 107 is shown
as a dashed line in FIG. 1 merely to indicate that information from
database 104 may or may not be used in different embodiments.
[0022] Wellness rules engine 109 uses member health score data and
member risk factor data to identify members who are at risk,
identify members who need or would benefit from wellness coaching,
and to monitor health and wellness status or activities. Wellness
rules engine 109 may apply a set of pre-defined rules to the
members' health score and risk factors and generate a list of
high-risk members (i.e. a high-risk population) within the group of
members. The high-risk population may be associated with specific
risk factors or diseases, such as high blood pressure, high
cholesterol, obesity, diabetes, or cancer.
[0023] Wellness rules engine 109 may provide data, such as a list
of high-risk members, to outreach engine 114, which in turn
provides data to incentives application 110. In one embodiment,
incentives application 110 may be used to suggest, develop and
manage incentives programs that are tailored to specific risk
levels within the member population and that are designed to
encourage those members to participate in wellness activities. A
high-risk member, for example, may be offered a reward for
performing a certain number of wellness tasks. In one embodiment,
if the member participates in the suggested tasks, then they are
eligible for the reward, such as entry into a drawing for a gift
card, prize, or monetary award. In another embodiment, incentives
application 110 may be used to assist a wellness coach to design,
develop and manage challenges for the high-risk population. For
example, a "biggest loser" challenge may be organized for a group
of members who have a body mass index (BMI) above a certain
threshold and who may improve their overall health by losing
weight. Wellness rule engine 109 and outreach engine 114 may
provide a list of members who have a BMI above the threshold to
incentives application 110. Wellness rules engine 109 may also
identify members who indicated an interest in losing weight.
Outreach engine 114 and incentives application 110 may facilitate
contacting and enrolling the members in the challenge and to
monitor their progress.
[0024] Incentive programs may be developed, for example, in
connection with an employer. The employer may use the incentives to
achieve certain goals, such as reducing the overall risk of disease
within the employee population. The incentive programs developed by
incentives application 110 may be specifically targeted to
particular disease categories, risk factors, member personalities,
or other disease or member characteristics. Outreach engine 114 may
identify members of the employers' health plan to be contacted
about the incentive programs. Preferably, the incentive programs
use techniques that support healthy activities or encourage member
participation. One goal of the incentives programs is to drive and
encourage participation in the available health management and
wellness programs. The incentive programs may offer positive or
negative incentives, such as a reduction or cancellation of
insurance coverage if a member fails to participate in an
assessment program or a lower insurance cost if the member's body
mass index is below a selected level. A program that is helpful to
one member, may not work for other members with different
personalities, jobs, families, or physical characteristics. For
example, some members may be more likely to participate in group
programs, such as group walks or weight loss competitions, while
other members are more responsive to individualized programs. To
help a member reach wellness goals, incentive application 110 may
adjust a member's incentive program if a particular program is not
working for the member. Incentive application 110 may establish
specific milestones for a member to meet as part of the incentive
program. For example, incentive application 110 may set particular
intervals, such as weekly or monthly periods, at which the member
should meet certain goals, such as a number hours of exercise, a
number of miles walked or run, or an amount of weight lost.
[0025] Member health management database 111, which is an
aggregated database of member health metrics, may also receive
information from wellness rules engine 109. Health management
database 111 allows a wellness coach, outreach professional, or
other user to store, sort and/or stratify member health data.
Health management database 111 may also interact with incentives
application 110 to provide data that would assist in the
development of incentive programs for members. Data from health
management database 111 may also be used to generate standardized
or ad hoc reports regarding a selected population's health. Member
health management database 111 may comprise records having specific
data sets for each member, such as incentive programs used by the
member, risk triggers, or coaching priority. Users may access, sort
and search the data in member health management database 111, for
example, to rank members by risk, health score, or claim costs.
This information may be fed back to wellness rules engine 109 to
further identify high-risk members or members who would benefit
from coaching. The information in member health management database
111 is continually updated as members biometric data and assessment
data changes and as the members participate in health management
activities.
[0026] Participation database 112 stores information regarding
members' participation and involvement in various activities, such
as incentive programs, coaching, classes, or other training or
activities. The information stored in participation database 112
may be used by wellness rules engine 109. For example, the wellness
rules in engine 109 may determine whether a member has been
participating in any incentive programs or wellness activities. If
the member does not participate in the suggested activities or
incentives, then wellness rules engine 109 may direct incentives
application 110 to generate a different set of incentives for the
member. Alternatively, wellness rules engine 109 or outreach engine
114 may notify a wellness coach or other healthcare professional
that the member is not participating in certain activities and
prompt the wellness coach to contact the member.
[0027] Outreach engine 114 may also exchange data with member
health management database 111 and participation database 112. In
one embodiment, outreach engine 114 uses the output of wellness
rules engine 109 to provide "on-demand" services. An outreach
professional may use data from outreach engine 114 to identify
and/or prioritize members who should be contacted for health
management services. Outreach engine 114 may generate automatic
messages to members based on selected criteria, such as particular
risk factors or health scores. Outreach engine 114 may also be used
to generate telephone queues, scripts, and questions to be used by
an outreach professional when contacting members.
[0028] Outreach engine 114 adds a human judgment element to the
operation of the health management system. A particular group of
members may be selected for promotional outreach, for example, such
as employees of a company that is conducting member screening.
Outreach engine 114 may also be used elevate or highlight the
priority of selected risk factors. For example, a particular risk
factor may be identified as a priority for health management during
a particular wellness campaign or within a certain organization.
Outreach engine 114 may provide outreach professionals with data
identifying the members to be contacted in connection with selected
risk factors. For example, outreach engine 114 may initiate or
support outreach to all members, regardless of risk level, to
provide promotional information, such as available programs,
assessment or screening dates, or other general information. In
another embodiment, outreach engine 114 may support lifestyle
outreach to members in high and moderate risk levels, such as
health improvement challenges or contests. Outreach engine 114 may
further provide clinical outreach to members with high risk
factors.
[0029] Health score engine 105, risk factor engine 107, wellness
rules engine 109, incentives application 110 and outreach engine
114 may be embodied as a software applications running on a
microprocessor device. In one embodiment, health score engine 105,
risk factor engine 107, wellness rules engine 109, incentives
application 110 and outreach engine 114 are components of a single
software application that may run on a central server device. In
other embodiments, two or more software applications running on two
or more server or microprocessor devices may be used to provide the
functionality for health score engine 105, risk factor engine 107,
wellness rules engine 109, incentive application 110 and outreach
engine 114. It will be understood that the system illustrated in
FIG. 1 is not limited to the connections shown. Other connections
among the illustrated components may be used in other embodiments.
Moreover, some connections are shown as arrows for purposes of
illustration only. It will be understood that information may flow
in both directions on such connections despite the arrow pointing
in one direction.
[0030] It will be understood that member assessment database 101,
member biometric database 103, member claim database 104, health
score database 106, and risk factor database 108 may be reside in
separate devices, such as separate memory or storage systems. If
configured in separate devices, member assessment database 101,
member biometric database 103, member claim database 104, member
health score database 106 and risk factor database 108 may be
established in the same location or in locations that are remote
from each other. Alternatively, all or any combination of the data
stored in one or more of member assessment database 101, member
biometric database 103, member claim database 104, health score
database 106 and risk factor database 108 may be stored in the same
memory device.
[0031] Terminal 102 may be located near to or remote from the other
components illustrated in FIG. 1. Terminal 102 provides access for
members, coaches, administrators, employers, brokers, physicians,
and others to member data, health scores, risk factors, training
courses and other information. Although only a single terminal 102
is illustrated, it will be understood that any number of terminals
102 may interact with health score engine 105, risk factor engine
107, wellness rules engine 109, coaching application 110, and
outreach engine 114, as well as databases 101, 103, 104, 106, 108,
111, and 112. Terminal 102 may be connected via a public or private
computer network to the other components illustrated in FIG. 1, or
may be connected via a wireline or wireless connection.
[0032] Terminal 102 may be used to run one or more of applications
113, such as coaching, member, employer, broker or physician
applications, that provide an interface between particular types of
users and health management system 100.
[0033] A coaching application may be used by a wellness coach,
outreach professional or healthcare professional to obtain a list
of high-risk members and to identify activities suggested by
wellness rules engine 109. The coaching application may be used to
facilitate coaching of the high-risk population toward a healthier
lifestyle. Additionally, the coaching application may provide
automatic coaching to members of the high-risk population. A
wellness coach may log-in to coaching application, such as by using
terminal 102. The coaching application may provide the wellness
coach or outreach professional with a list of tasks to accomplish
with the high-risk population. The coaching application and/or the
outreach professional may use incentives, challenges, training,
reminders, feedback, and other member interaction. The coaching
application may also generate suggested actions for the members who
are participating in the challenge, such as dietary and exercise
suggestions for the wellness coach or outreach professional to
discuss with the participants.
[0034] A coaching application may also be configured to provide
automated coaching, such as generating emails, letters, or text
messages to members or secure messages to members having a common
risk factor. The present invention provides HIPAA-compliant
messaging, such as secure, 128-bit encrypted messaging for
communicating medical, health, risk factor or individual coaching
information to a member. For example, the coaching application may
generate an email to a member having a high LDL cholesterol level
to suggest particular foods that may help to improve cholesterol or
to recommend avoiding other foods that would increase cholesterol
levels. The coaching application may also assist the wellness coach
in keeping track of high-risk members, such as by providing
periodic or non-periodic reminders to follow-up with particular
members.
[0035] The coaching application may also identify when a member's
assessment, biometric or claim data is changed or updated. For
example, if the member visits the doctor, new claim data 104 or
biometric data 103 may be collected and forwarded to risk factor
engine 107, which may identify new risk factors or may determine
that certain risk factors have been reduced or eliminated. A member
who has been identified with a high blood pressure risk factor, for
example, may have a good blood pressure reading during a doctor
visit. The coaching application may identify the change in the high
blood pressure risk factor and notify the wellness coach or
outreach professional, who may contact the member to provide
positive feedback to the member and to encourage him to continue
healthy activities.
[0036] In one embodiment, the present invention uses a combination
of self-reported data, such as a member assessment, and objective
data, such as biometric screening, to generate a list of risk
factors for members. Wellness rules are applied to the risk factors
to assist a wellness coach or outreach professional in identifying
high-risk members. The wellness coach may then use the coaching
application to stratify and group the high-risk members, such as by
collecting data from member health management database 111. For
example, a first group may be identified as potential participants
in a challenge, such as a biggest loser competition; a second group
may be identified for an incentive program, such as a drawing for a
gift card if they run more than 5 miles a week; and a third group
may be identified for reminder emails to eat healthy foods, such as
certain vegetables. The coaching application may be used to manage
a wellness program for a diverse group of members. The group may
include members from different employers and/or different insurance
plans.
[0037] In other embodiments, the coaching application may provide
training and/or informational courses for use by a wellness coach,
outreach professional, and/or member. For example, video, audio,
interactive, static or other courses, information or training
materials may be available through the coaching application. The
course may be available to members who indicate an interest in
learning about certain health or wellness topics, for example.
Other members with specific risk factors may be notified of courses
related to disease prevention. A wellness coach may want to learn
about a new wellness program or refresh her knowledge about certain
diseases. The members and/or wellness coach may access the courses
using terminal 102, for example. Alternatively, the members or
wellness coach may request that an electronic or paper copy of a
selected course or training materials be sent to the user.
[0038] The members' health scores may be used, in one embodiment,
to evaluate the effectiveness of a selected wellness coach. For
example, a coach evaluation application may use individual member
health scores and/or an aggregate member health score to determine
if the programs being used by a particular coach are successful or
not helpful to the members. The relative improvement of members'
health scores may also be used to adjust wellness rules engine 109
and incentives application 110. Programs associated with low or no
health score improvement may be canceled or modified. Additionally,
the coach may receive feedback based upon the evaluation, which
would help to improve the coach's performance and
effectiveness.
[0039] A member application provides an interface that allows
members to log onto the system using a terminal such as 102. The
members may monitor their health scores and risk factors using the
member application. Additionally, members may use the member
application to participate in incentive programs, communicate with
wellness coaches, use training materials and other components of
system 100.
[0040] An employer application and an insurance broker application
may also be used to interface with system 100. For example, an
employer or broker may review individual and aggregate member
health scores. Member health scores and risk factors for a group
may be used to determine the type of insurance premiums and plans
that should be considered for that group. The member health scores
may be analyzed by an employee, member, employer, coach, or broker.
If an employee group does or does not have certain risk factors,
then the availability and cost of coverage for diseases associated
with that risk factor in various insurance plans may be relevant to
the employer when selecting insurance coverage.
[0041] In one embodiment, risk factors may be identified using
claims data for a group, such as a group of employees. Claims data
may be obtained from companies that analyze and process insurance
claims. The raw claims data may be processed by health score engine
105 to generate health scores for a group. The raw claims data for
a group also may be used by risk factors engine 107 to generate a
list of risk factors for the group or for individual members. The
overall risk for the group may be evaluated using the risk factor
data generated by engine 107.
[0042] The claims data may be used to compare health cost spending
among different companies. For example, the cost per employee per
year may be calculated for one or more companies. Those costs may
be compared between competitor companies, for example, so that a
company may evaluate its own healthcare or insurance spending
against industry benchmarks. The claims data and the members' risk
factors and health scores may also be used to correlate risk
factors to healthcare costs. This would allow employers, for
example, to evaluate what risk factors are driving their healthcare
costs and to determine what factors comprise the healthcare costs.
The costs for members may be further stratified based upon risk
factor so that an employer may evaluate the cost per employee per
risk factor per year, so that the employer may identify the highest
cost risk factors. Those high-cost risk factors may be then used by
outreach engine 114 and/or incentives application 110 to identify
employees to be targeted for outreach programs that are aimed at
reducing and managing the high-cost risk factors. This would
provide the employer with tools for managing and reducing future
healthcare costs.
[0043] An employer or broker application may provide cost-based
analytics using the health management, risk factor and claims data.
The cost-based analytics provide an analysis of healthcare costs
based on stratifications of the employees' risk factors. The
cost-based analytics would help to calculate the employer's return
on its investment in healthcare costs by showing whether the
employer's health plan has been successful in reducing high-cost
risk factors and in reducing predicted healthcare costs associated
with those risk factors.
[0044] Physicians or other healthcare professionals may also access
system 100 using a physician application. Physicians may use the
application to enter data, such as member biometric data, or to
review members' health scores, risk factors, or incentive
programs.
[0045] FIG. 2 is a flowchart illustrating a method for implementing
one embodiment of the present invention. In step 201, member
assessment data is collected, such as using an on-line or hard copy
questionnaire or survey. In step 202, member biometric data is
collected, such as during a medical check-up or assessment
examination. In step 203, member claims data is collected, such as
from a claims processing service or insurance company. In step 204,
risk factors are generated for one or more members based upon the
member assessment data, member biometric data, and/or member claims
data. In step 205, health scores for one or more members are
generated based upon the member assessment data, member biometric
data, and/or member claims data. The health scores and risk factors
may be stored for later use, such as for evaluating the current or
historical health of a member or group of members. A wellness
coach, outreach professional, member, administrator, insurance
broker, or other party may have access to the health scores for
analysis.
[0046] The health scores and risk factors may be stored for use by
other applications, such as in step 206 in which the risk factors
are analyzed using a set of wellness rules to identify members of a
population stratified based on risk. The population may be
stratified into low, moderate and high-risk members. High-risk
members may include, for example, members who have a plurality of
risk factors for a particular disease, or who have one or more key
risk factors for the disease. The wellness rules may be configured
to assist in evaluating the number and/or importance of the risk
factors to identify a higher likelihood that a member may develop
the disease. The health management services provided using the
present invention may be used in some embodiments to also help low
and moderate-risk members from developing additional key risk
factors that would put them in a high-risk category.
[0047] In step 207, incentive programs are identified for members
of the stratified population. An incentive application may use
information from a wellness rules engine and/or a member health
management database to select or develop the incentive programs. In
step 208, a wellness coach, outreach professional or other
individual may then provide outreach services to members of the
stratified population. The services may be selected based upon the
risk levels of various members of the population. The outreach
professional may monitor or support the incentive programs or other
activities, such as challenges, courses, or email and text
messages. A coaching application may be used by the wellness coach
or outreach professional to identify members who are eligible for
and likely to benefit from coaching. The coaching application may
also provide tools to assist the wellness coach or outreach
professional to design, implement, and manage wellness programs for
members.
[0048] For example, a member may submit an assessment, participate
in a biometric examination, and/or approve the release of claim
data. In one embodiment, the risk factor engine may determine that
member's assessment and/or biometric data indicates that the member
has a high risk for diabetes, such as a family history of the
disease or a high blood sugar measurement. The wellness rules may
suggest that the member should have a glucose tolerance test. If
the member's claim data indicates that he or she has not yet had a
glucose tolerance test or other follow-up regarding diabetes, then
the coaching application 113 or outreach engine 114 may prompt the
wellness coach to contact the member to suggest such a follow-up.
The incentive application may suggest that the wellness coach
recommend a course on diabetes to the member or suggest other
information to be sent to the member in an email or text
message.
[0049] In other embodiments, if a member is identified as having
high cholesterol, he may be identified as being in a high-risk
group. The wellness rules may suggest that the member see a doctor
about the problem and/or have a prescription for cholesterol
reducing medication. If there is no indication that the member has
taken these steps, then the coaching application 113 or outreach
engine 114 may suggest that the wellness coach or outreach
professional contact the member and/or provide the member with
information regarding the effects of high cholesterol levels and
ways to reduce those levels.
[0050] In another embodiment, female members over age 40 who have
not had a recent breast cancer screening may be assigned to a high
risk category by the risk factors engine. The coaching application
113 or outreach engine 114 may automatically send email or text
messages to women in this group, or suggest that the wellness coach
or outreach professional contact these women, to suggest they
schedule a mammogram.
[0051] A method for providing health management and/or wellness
services may comprise collecting member health assessment data and
member biometric data. A health score and risk factors for each
member are identified based upon the member assessment data and the
member biometric data. A high-risk population is then identified by
applying a set of wellness rules to the health scores and risk
factors. One or more incentive programs may be selected for the
high-risk population. A wellness coach may also provide coaching to
the high-risk population to participate in an incentive program or
other wellness or health management activity. The coach may
encourage the members to participate in competitions, challenges,
exercise programs, nutrition programs, and/or educational programs.
The members' participation in incentive programs may be monitored
and used to refine the incentive programs recommended to the
members. Other incentive programs may be developed for other risk
groups, such as members at moderate and low risk, to encourage
those members to maintain a reduced risk level.
[0052] The member health assessment data may include, for example,
a members' self-evaluation of various health metrics such as the
members' nutrition, physical activity, stress, tobacco use, alcohol
use and sleep habits. The health assessment data may be collected
using one or more questions directed to each of these health
metrics. The potential answers to each of the health metric
questions may be assigned a health score point value. The point
values for each of a member's answers may be added or otherwise
combined to calculate the member's health score. Additionally, the
potential answers to each of the health metric questions may be
assigned a risk level. The risk level for each of a member's
answers may be evaluated to identify the member's risk factors. For
example, a health assessment survey may include health metric
questions directed to the member's nutrition, such as a question
related to how often the member drinks at least eight 8-ounce
glasses of water a day. Each of the answers options may be assigned
a risk level and a health score point value, as illustrated in the
example of Table 1.
TABLE-US-00001 TABLE 1 Q: On average, how many days each week do
you drink at least eight 8-ounce glasses of water? Answer choice
Risk Level Point Value 0 High 0.24 1 High 0.24 2 High 0.24 3
Moderate 0.42 4 Moderate 0.42 5 Low 0.60 6 Low 0.60 7 Low 0.60
[0053] Table 2 illustrates another exemplary risk level and health
score point value assignment for another health metric question
related to tobacco use. The user is presented with several possible
answer and each option is assigned a relative health score point
value and risk level value.
TABLE-US-00002 TABLE 2 Q: How often do you use tobacco products
such as cigarettes, cigars, pipes, snuff, chewing tobacco, etc.?
Answer choice Risk Level Point Value Daily High 0.56 Occasionally
High 1.12 Rarely Moderate 6.86 Never Low 9.80
[0054] It will be understood that any number of questions may be
associated with a particular health metric and that different
numbers of questions may be used for different health metrics
depending on how specifically a wellness or health management
provider wants to evaluate each individual health metric. For
example, one question may be used to evaluate overall tobacco use,
such as shown in Table 2, or the health assessment survey may use
multiple questions, each directed to the use of specific tobacco
products.
[0055] The member biometric data may comprise objective
measurements of a member's medical factors, such as blood pressure,
cholesterol level, triglycerides level, glucose level, and body
mass index. These measurements may be made by a healthcare or
wellness professional and/or collected from laboratory analysis of
the member's blood sample or other specimens. Each biometric
parameter measured in the biometric data may be divided into
different measurement ranges. The different ranges may be assigned
a health score point value. The point values for each of the
member's biometric data measurements may be added or otherwise
combined to calculate the member's health score. The different
measurement ranges for the measured health factors may also be
assigned a risk level. The risk levels for the biometric data
measurements may be evaluated to identify the member's risk
factors.
[0056] Table 3 illustrates a risk level and health score point
value assignment for a health factor related to the member's total
cholesterol. The measured cholesterol value, such as determined by
laboratory analysis of the member's blood specimen, will fall
within one of the specified ranges. The member's total cholesterol
measurement is assigned a corresponding risk level and health score
point value, as illustrated in the example of Table 3.
TABLE-US-00003 TABLE 3 Total Cholesterol Measurement Risk Level
Point Value <200 Low 3.00 200-240 Moderate 2.10 >240 High
1.20
[0057] Other biometric measurements may be evaluated and assigned
risk levels and health score point values, such as blood pressure
measurements, glucose measurements, and BMI calculations. These
factors may be evaluated using more specific measurements, such as
specific LDL cholesterol and HDL cholesterol measurements, or
ratios between different factors or measurements.
[0058] It will be understood that the risk level values and health
score point values that are assigned to health assessment survey
questions and to biometric measurements may be generic for both
sexes and all races and ages. Alternatively, age-, race-, and/or
sex-range specific values may be established for individual survey
questions or biometric measurements if it is determined that a
particular health factor or biometric has varying significance to
different members of the population. Accordingly, the health score
point values and risk level values may be further refined for
specific groups of the population. For example, it might be
determined that the impact of tobacco use on health varies
depending upon age, the impact of alcohol use on health varies
depending upon sex, and the impact of glucose levels on health
varies depending on race. For each of these factors, age-, sex-,
and race-specific health score point value and risk level value
assignments may be developed.
[0059] The health score points for each health survey question and
biometric may be combined to generate a member health score. As
illustrated in Table 4, the point values for the member's answers
to health survey questions, such as the member's answers to the
questions in Tables 1 and 2 above, are added together with the
point values assigned to the member's other survey answers.
Additionally, as shown in Table 4, the point values for the
member's biometric measurements, such as the biometric data for the
total cholesterol biometric in Table 3, are also added to the
health survey point values to give the overall member health
score.
[0060] The health assessment health score points and the biometric
health score points may be weighted separately to calculate the
total health score. For example, if the heath management provider
determines that the biometric data is overall more important to the
health score determination than the health assessment questions,
then the biometric measurements may be weighted more in calculating
the total health score. As illustrated in Table 4, the biometric
data may be weighted as 60% of the total health score and the
health assessment data as 40% of the total in one embodiment. Table
4 is intended as an illustration of exemplary health survey
questions and biometric measurements used to calculate a member's
total health score. The point values and total health score in
Table 4 are merely presented for illustration and are not intended
to be limiting features of the invention. In one embodiment of the
invention, for example, 20 health survey questions and multiple
biometric measurements may be used and point values assigned so
that the typical health score is on a scale from 0 to 100.
TABLE-US-00004 TABLE 4 Member #1 Risk Level Point Value Health
Survey Water intake question Moderate 0.42 Questions Tobacco use
question High 0.56 Question #3 Low *** Question #4 Moderate ***
Question #5 High *** Sub total ### Biometric Total Cholesterol Low
3.00 Measurements Biometric #2 Low *** Biometric #3 Moderate ***
Biometric #4 High *** Sub total ### Health Assessment Adjustment
(40% of total) *** Biometric Adjustment (60% of total) *** Total
Health Score 85.50
[0061] The member's risk factors may also be identified from the
summary information shown in Table 4. For example, the member is at
high-risk for health issues related to tobacco use. The member is
also at high risk for health issues related to the subject matter
of question #5 and biometric #4. Question #5 may be directed, for
example, to physical activity, and the member's answers indicated
little or no exercise. Biometric #4 may be directed, for example,
to glucose levels, and the member's blood work may indicate high
glucose levels.
[0062] Table 4 is merely an exemplary summary of the health
assessment data and risk factor data collected for one member. As
noted above, it will be understood that any number of questions may
be included in a health assessment survey, and that any number of
biometric parameters may be measured in embodiments of the
invention. Moreover, the relative point value and risk level
associated with each question and biometric may be adjusted by the
health management provider as appropriate.
[0063] A set of wellness rules may be applied to the member's
health score (e.g. 85.50) and risk factors (e.g. tobacco, physical
activity, and glucose levels). The wellness rules may provide data
to an incentive application (FIG. 1), which would develop
incentives to help the member reduce his risk factors. For example,
the incentives engine may suggest activities, classes, or support
to help the member reduce tobacco use, to begin exercising, and to
follow a diet that would lower glucose levels.
[0064] The data illustrated in Tables 1-4 for a single member may
be collected, measured and calculated for a plurality of members,
such as a group of employees. The wellness rules may be used to
identify and stratify members by risk factor, such as by
identifying how many members are at high risk for each factor and
identifying which members have the most high risk factors. Table 5
illustrates an exemplary summary of the health risks for a
population of users, such as an employee group, across six risk
factor categories.
[0065] The health management system may be used to identify the
members of the high risk group in each risk factor category. Those
members may be specifically targeted for coaching to lower their
risk factor for those specific categories and thereby lower their
likely of becoming ill, developing a disease and/or requiring
medical care.
TABLE-US-00005 TABLE 5 Risk Levels and Number of Participants in
Category Risk Factor Categories High Moderate Low Total Tobacco 117
21 141 279 Physical Activity 107 125 47 279 Glucose 38 93 148 279
Total Cholesterol 40 48 191 279 Factor #5 50 180 49 279 Factor #6
100 166 13 279 Factor #7 154 92 33 279 Factor #8 19 118 142 279
Factor #9 45 136 98 279
[0066] Table 6 illustrates an exemplary population analysis for a
group of members, such as an employee group. The data in Table 6 is
stratified by risk to illustrate the distribution of risk factors
among the members. If a member has a risk level of high for any of
the categories, then the member is considered to have a risk factor
for that category. The number of risk factors column indicates that
among the illustrated group, the members had on average 3.9 risk
factors. Four members had no risk factors, and five member had all
nine identified risk factors. The health management system may be
used to identify members who have an overall high risk level, such
as members with 5 more risk factors. Those members may be targeted
for coaching to reduce their risk factors and to improve their
overall health. The coaching may be tailored to the particular
group of risk factors associated with that each individual.
TABLE-US-00006 TABLE 6 Member Number of Risk Number of Percentage
of Risk Level Factors Members Members Total 3.9 Average 274 100.0%
Low 0 4 1.5% 1 29 10.6% 2 45 16.4% Moderate 3 45 16.4% 4 47 17.2%
High 5 52 19.0% 6 29 10.6% 7 10 3.6% 8 8 2.9% 9 5 1.9%
[0067] In another embodiment, the risk factors may be individually
weighted so that selected critical risk factors are prioritized.
Such weighting of risk factors may result in more members falling
in a moderate or high risk group. By weighting certain risk
factors, embodiments of the present invention may be used to
identify the possibility of and to prevent "risk migration" in
which members' risk factors become worse over time.
[0068] Although the present invention and its advantages have been
described in detail, it should be understood that various changes,
substitutions and alterations can be made herein without departing
from the spirit and scope of the invention as defined by the
appended claims. Moreover, the scope of the present application is
not intended to be limited to the particular embodiments of the
process, machine, manufacture, composition of matter, means,
methods and steps described in the specification. As one of
ordinary skill in the art will readily appreciate from the
disclosure of the present invention, processes, machines,
manufacture, compositions of matter, means, methods, or steps,
presently existing or later to be developed, that perform
substantially the same function or achieve substantially the same
result as the corresponding embodiments described herein may be
utilized according to the present invention. Accordingly, the
appended claims are intended to include within their scope such
processes, machines, manufacture, compositions of matter, means,
methods, or steps.
* * * * *